Medsider: Learn from Medtech and Healthtech Founders and CEOs - Why Your Medtech Strategy Should Start with Healthcare Payers: Interview with Health Economist Nic Anderson

Episode Date: October 6, 2021

In this episode of Medsider Radio, we caught up with health economist, Nic Anderson, who spent seven years at Intermountain Healthcare on the payer side. He learned first-hand what evidence insurers need to convince them to cover a new medical device or healthcare technology. After co-founding a biotech company, Nic turned his experience as a payer into an in-demand consultancy. He’s also served on payer advisory boards and was an expert in residence at a digital health accelerator in Dubai. He now works as a health economist for Boston Scientific.In this conversation, Nic explains why medtech companies, in particular, need to win over insurance payers, how investing early in a health economics and market access (HEMA) team will help you do that, and how to write a dossier a payer won’t want to throw out the window.Before we jump into the conversation, I wanted to mention a few things:If you’re into learning from proven medtech and healthtech leaders, and want to know when new content and interviews go live, head over to Medsider.com and sign up for our free newsletter. You’ll get access to gated articles, and lots of other interesting healthcare content. Second, if you want even more inside info from proven experts, think about a Medsider premium membership. We talk to experienced healthcare leaders about the nuts and bolts of running a business and bringing products to market. This is your place for valuable knowledge on specific topics like seed funding, prototyping, insurance reimbursement, and positioning a medtech startup for an exit.In addition to the entire back catalog of Medsider interviews over the past decade, Premium members get exclusive Ask Me Anything interviews and masterclasses with some of the world’s most successful medtech founders and executives. Since making the premium memberships available, I’ve been pleasantly surprised at how many people have signed up. If you’re interested, go to medsider.com/subscribe to learn more.Lastly, here's the link to the full interview with Nic if you'd rather read it instead.

Physicians will oftentimes buy off of what's called clinical validity. They don't necessarily buy off of clinical utility, the higher bar of evidence. Well, the insurance companies always reimburse off of clinical utility. So if you go above and beyond, if you keep your eye on clinical utility and you make sure that you're giving Aetna, Cigna, United, and so on, what they want, you will almost by accident give the physician what they want. Welcome to Medsider Radio, where you can learn from proven medtech and healthcare thought leaders through uncut and unedited interviews. Now, here's your host, Scott Nelson.

Hey, everyone, it's Scott. In this episode of Medsider Radio, we're chatting with health economist Nick Anderson, who spent seven years at Intermountain Health Care on the payer side. He learned firsthand what evidence ensures need to convince them to cover a new medical device or healthcare technology. After co-founding a biotech company, Nick turned his experience as a payer into an employer into an insurance. in-demand consultancy. He's also served on payer advisory boards and was an expert in residence at a digital health accelerator in Dubai. He now works as a health economist for Boston Scientific. In this interview, here are a few of the things we chat about. First, medical companies often spend too much time trying to sell physicians on their novel devices or technology when it's

actually the payer who decides whether it merits coverage. No coverage means doctors won't be able to get their hands on it, whether they want to or not. Second, bringing a specialized health economics and market access sales team on board from the start will ensure the evidence you gather throughout clinical trials is tailored to prove your case to payers, saving you time and money in the long term. Last, acquiring a unique CPT or Hickspix code doesn't guarantee you coverage, and neither does meeting regulatory requirements. Payers often require more evidence than the AMA, CMS, or FDA,

and want proof that specifically focuses on the economic, benefits of your medical technology. Okay, so before we jump into the discussion, I want to mention a few things. First, since you're listening to Medsider, you're probably aware of how expensive it is to run clinical trials. Anyone who spent time in the MedTech space knows that you typically need to commit hundreds of thousands of dollars, oftentimes millions, towards clinical research. But it doesn't have to be that way.

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Okay, second, if you're into learning from proven MedTech leaders and want to know when the new content and interviews go live, head over to Medsider.com and sign up for our free newsletter. You'll get access to gated articles and lots of other interesting healthcare content. If you want even more inside info from MedTech experts, think about a MedSider premium membership. We talked to experienced healthcare leaders about the nuts and bolts of running a business and bringing products to market.

This is your place for valuable knowledge on specific topics like seat funding, prototyping, insurance reimbursement, and positioning a MedTech startup for an exit. In addition to the entire back catalog of MedSider interviews over the past decade, premium members get exclusive Ask Me Anything interviews and masterclasses with some of the world's most successful MedTech founders and executives. Since making the premium memberships available, I've been pleasantly surprised at how many people have signed up. So if you're interested, go to Medsider.com to learn more.

All right, without further ado, let's get to the interview. Hey, Nick, welcome to Medside Radio. Appreciate you coming on. Thanks, Scott. It's good to be here. Absolutely. I'm looking forward to this conversation. Ever since I remember the first kind of large kind of health economics or semi-large health

economics kind of reimbursement project I was involved with at Kavidian. And ever since then, it was like this whole world is like super intriguing to me. You know what I mean? So I love talking shop with experts like yourself. So I'm looking forward to hopefully going a little bit deeper on this, on this. subject matter because it's so important for anyone in med tech or health tech to kind of understand at least at a high level. So really, I think this discussion will be good. So with that said, I gave the folks listening a high level kind of background or bio about yourself, but do you want to

maybe add your elevator pitch or maybe some add a little bit of context to kind of your, both your personal and or professional background? You bet. So yeah, thank you again for having me. So I'm, I'm originally from Utah. I went to school at Purdue and then studied neuroscience and then went to Boston University School of Medicine. But I did a master's degree there in medical imaging, ultrasound, MRI, all of the physics behind how these machines work.

And it was amazing. I did my thesis on MRI and how the brain changes with age, just to summarize it. But I remember during some of these classes, I would, the professor would put up an image of an MRI or something and say, well, this patient had gadolinium and we ran a T1 weighted pulse sequence and we did this and this and this. And I kept asking the whole time, well, how much does that one cost? Well, how much is gadolinium? Well, why didn't you just do a stir sequence or a flare sequence or why didn't you do this and this and this?

Because if those are cheaper, because you don't have to use the gadolinium. And, you know, after probably annoying him to death over the whole course of the program, it was kind of like, I was the only guy that seemed to care about how much all this stuff cost. And he would answer, I don't know how much it costs. I just run the sequence that I'm supposed to run in my research. And I was like, well, yeah, but there's a cost to this stuff. So, Scott, I think I was a natural born health economist. You know, I didn't go to health economic school to do this.

I have a good science background, and then I kind of worked my way into it. Well, my wife and I moved back to Utah. I took a job at Intermountain Healthcare. Intermountain is an integrated delivery network, so you have both the hospitals and the insurance company, and my desk was at the insurance company. But I was also on Intermountain Healthcare's Value Analysis Committee. So I was on the hospital side and on the insurance side, but my job was to review all of these technologies.

I mean, you name the technology, Eurolift or MRI compatible pacemakers or KoloGuard. You know, Nick, you do the review on that. You don't have a dog in the fight. No one's a shareholder in Intermountain Healthcare. It's a nonprofit company. So whether we use this technology or not should only be based off of the evidence that has been published and the cost that we have to pay for these things. So anyway, I did that for seven years.

I was at Intermountain and Select Health. I bounced between the two and did health economics and health technology assessment. And then I started a biotech company with some friends. That was an amazing experience. I left that company and now I work full time with Boston Scientific as a health economist in the peripheral intervention, peripheral vascular disease, interventional oncology group. So all health economics, I don't know anything. other than health economics and market access.

Yeah, no, that's great. So I often referred to folks that I interview for Medside Radio's as, you know, if they have the experience of sitting on both sides of the table, right, as an investor and then as maybe like a startup founder. And you've sat on both sides of the table, right, when it comes to, you know, healthcare economics is both on the kind of the payer kind of covered side, but now obviously working with a fair amount of biotech and MedTech clients and then obviously with Boston scientific, as you just mentioned.

So I think you bring a pretty unique, unique perspective in terms of, you know, how, you know, how the sausage is made sort of, right, behind the scenes. And I know I want to get into some of these topics that we kind of discussed in advance of this interview. But you made a really good point in kind of our back and forth email exchange that, you know, in talking about CPT codes, right? Because that's what most people think of when when they think about whether or not their health tech device or their medical device is going to be, is going to, is going to make it, right? is there a clear CPT code? You made a really good point that, like, yes, that's clearly important. But just because there's a CPT code exists, you know, unless it's like a commoditized product, like that doesn't mean, you know, an Intermountain Health or any other like payer is going to actually like cover and reimburse for this technology.

And so with that said, let's start with maybe like some of the key before we jump into the details. Like what are some of the most common mistakes that you see MedTech, health tech companies, make when it comes to the world of health care economics and insurance coverage and reimbursement? Yeah, the number one mistake, in my opinion, again, this is just me speaking. I'm not speaking on behalf of any company other than me. The number one mistake that they make is they think the physician is the customer. And the physician is effectively the purchasing agent, as they were once called, that the physician is an individual that says, I know what patients need, I'm the one that touches them and I want a device that does this, this and this. Well, if you have children,

children want things too. They want toys. Now, I'm not comparing a physician to a child. I'm using an analogy. The physician said, a child says, mom, I want this new toy. And if you're the CEO of Mattel or Fisher Price and you think the child is the customer, you're grossly mistaken. The child, the one that says, I want the thing. And then you got to go talk to. mom and dad and go, mom and dad, are you willing to finance this? And mom and dad go, no, we're not. So the easy solution to this is do not take your eyes off of Aetna, Cigna, United, and Blue Cross. They are the customer, 99% of the time. If your product's commoditized, like you mentioned, Scott, if it's another catheter, another, you know, urinary catheter type thing, if it's another

gauze pad, another ace bandage, we'll then know. I mean, you don't need Etna and Cigna. And furthermore, etna and Cigna won't review your product. They'll be like, this is commoditized. We already have a medical policy about it. We let the hospital and physician decide which of the gauze pads they want to use. But if you have a novel new technology, something that is truly different, you've got to keep the fact, you've got to keep your eye on the fact that the insurance company is the customer. give them what they want and almost by default you'll end up giving the physician what they want. But it doesn't work the other way around. Physicians will oftentimes buy off of what's called clinical validity.

They don't necessarily buy off of clinical utility, the higher bar of evidence. Well, the insurance companies always reimburse off of clinical utility. So if you go above and beyond, if you keep your eye on clinical utility and you make sure that you're giving Aetna, United and so on what they want, you will almost by accident give the physician what they want. But like I said, it doesn't work in reverse. I think that's the biggest mistake that I see. People will be like, hey, we have the chief of surgery from Cedar Sinai on our board, and we have the chief of this from, you know, this big institution,

and the chief and the chief and the chief all on our board of directors. We're going to nail it. And you go, you understand you don't have anybody from Cigna on your board. you probably should. You don't have anyone from United Healthcare on your board. You probably should that those are the guys who write the checks, not the doctor. Yeah. Such a good point. And it's like, it's so pragmatic too because you scroll, you know, you scroll through any about section on a med tech or health tech startup website. All as you see typically on the advisory board are docs, usually, right? Docs are investors. But rarely, rarely, I'm trying to even remember the last time I saw

a VP or some senior level executive from a big payer, you know, like the ones that you mentioned, Cigna, Blue Cross, United, et cetera. And that's such a good point. I love your analogy, too, around the sort of the toy story, I guess, right? It's easy enough to say. But that's, that's so perfect, right? I mean, you're ultimately, you know, if the, and I don't, I'm not, I don't mean this in a demeaning way by any stretch of the imagination. The physician is not a child, but like, you know, they're ultimately like, yes, you need, them to have interest in using it for their patients. But like they're ultimately like at the end of the day, you need buy in. You need buying from a, you know, from the, uh, someone's got to pay for it.

Right. And so, um, I love that. I love that analogy. So let's, let's actually use it as a, as a kind of a transition point and take us back to your time at Intermountain, right? You said you, um, your office was on the insurance side, but you, you, you participate in all these value analysis teams, you know, um, on the provider side, uh, with their Intermountain. And it's such unique environment within Intermountain because of the synergy, you know, that they, how proactive they've been, you know, in terms of on the provider and payer side. But with that said, like, what did you need to see in order to say yes, right, in one of those committees to a new technology? And again, just to frame this up, we're not talking about a commoditized, you know, product like a balloon or a stent

or something like that or a hip implant. We're talking about something truly innovative and novel. So what was typically required? You mentioned clinical utility, but can you give us a little bit more context around what would get you kind of over the hump and get your buy-in to cover something like this? Yeah. So some of the answer to that, Scott, is how the technology even came to me in the first place. Because I work in that nameless, baseless building over there, you know, on the other side of the freeway where nobody visits. And how do I even find out about the technology to begin with? You know, like I said, whether it's KoloGuard or Eurolift or, you know, one of these new technologies. And the way that it probably should work in the current health care world we have

is that one of those companies would get a KOL excited at the hospital. And again, Scott, just for clarification, I'm not calling physicians children. Like, I'm just giving an analogy. Yeah. You know, there's probably some other analogy I could come up with that doesn't even borderline. I think we're on the same page. If any docs are listening, I'm hopefully they, they, you know, they don't take this too serious. But it's a good analogy, I think, because most people are listening and there's probably a high percentage of people that are listening that understand this because they have kids, right?

And so they've been through this dynamic. Yeah. Yes. There's a kid at the hospital that they end up saying, hey, here's this thing that you could use on these patients. And that individual said that physician or physical therapist or whoever it is, the credentialed provider with the insurance company, that credentialed provider says, wow, this is really cool. let me call Nick. And they call Nick over at the health insurance company and they say, Nick,

long time, no C. I have this really cool technology called Eurolift and you staple it into the prostate and it avoids the surgery and the surgery is expensive and there's all these complications like impotence and incontinence and Eurolift is effective and inexpensive and I think you'd really like it. And then I talked to doctor in this case, Jay Bischoff, and I'd say, say, Jay, that's fantastic. Would you send me their dossier? And he could be like, well, do you just want to talk to them? And almost 9.9 times out of 10, I would say no. I don't want to hear their sales pitch. You can listen to their sales pitch and PowerPoint all day long. I don't want it. I just want their dossier. And hopefully Jay Bishop has that dossier, you know, 120 pages, 68 pages, whatever it is. And he goes, sure, I'll meet you in the parking lot in an hour. I'm not kidding, like it would work this way.

And he drives over and hands me their dossier. And I go, okay, thanks, Jay, talk to you later, tell the wife and kids hi. And I go upstairs and I get to work. And I open up PubMed. I open up Hayes. I open up Cochran. I open up C-A-D-T-H and O-H-T-A-S and all of these databases that I have access to, either that we pay for or open public databases.

I crack my knuckles. and I start doing work on trans urethral prostatic lift system. That's one search term. Another one will be Eurolift. Another search term will be non-invasive, or minimally invasive, prostate, you know, whatever. And I get to work. And hopefully their dossier is guiding me in my research. And I do have a funny story about Eurolift.

I probably worked on it for a month before, not full-time. I work on a bunch of projects at once. but I wasn't finding nearly as much evidence as I thought there would have been, and I realized I needed to do transurethroprostatic lift system. I came across that term somewhere. Well, that was a failure, in my opinion, of NeoTrack, for not educating Jay Bischoff to educate me and so on and so forth, that how was I supposed to just come up with that term?

I mean, that's not a common term for this. So anyway, that's how it would come to me. I would get that dossier. I would write what's called an HTA. It's an internationally known term, health technology assessment. I write an HTA, and I present that to our committee, and I go, guys, this one's pretty good.

Vis-a-V transurethoretoreoresection of the prostate, TIRP, or TUNA, or T-U-M-T, or radical prostatectomy, or any one of these drugs, this thing is quicker, cheaper, better, faster, stronger. And then the committee goes, thank you, Nick. we will talk now. And I would chime in, but I wouldn't vote. I wasn't allowed to vote on the committee.

My report, my HTA was my vote. And the medical director would write his comment in there saying, hey, the evidence is good. I'm being colloquial with this, right? The evidence is solid from 12 peer-reviewed prospective studies, 16 retrospective studies, blah, blah, blah, blah, blah. We have gone and talked to our actuaries, And we said, hey, guys, how many men had BPH last year that we received a claim for?

And Julian Wadsworth would poll that for me and say, Nick, we had 1,642 men last year. Great. How many of those had TUMT? 28. Okay. How many of those men had TIR? So on and so forth. How much did we pay for all of those?

Now, let's go back to the dossier, page 84. And it says it is $1,000. for Eurolift. I'm making up the price, Scott. I can't remember, but it's $1,000. And their 12-month durability of effect is X, and their 30-day revision rate is Y. This minus this plus this divided by this,

says this is pretty good technology. And in the United States, we're not allowed to deny coverage on cost. You can in Europe. But we would take that into consideration. We're a company, and we have all the right in the world to look at what this is going to cost our members. Do we have to raise their premiums 25 cents per member per month next year if we cover Eurolid?

So that's kind of how that sausage was made. That was, what I just described, Scott would actually be a really pretty good scenario. The physician that's already spoken with the sales rep gets the dossier and drives it across the street to me and I take it and I go do my work. Normally it was much more jumbled than that. Hmm. Well, just to interrupt, so it's interesting that you mentioned Eurolift because like back, it's probably been about five years ago. Now I interviewed Ted Lamson, one of the co-founders of NeoTrac and makers of the EuroLeft device. So it's interesting that you're how small this, this world really is, right? And if you're listening to this and want to learn more about that story, you know,

I just do a search on Medsider for Ted Lamson or just Google search Ted Lamson and NeoTrack and you'll find the interview. But with that said, when you think about this dossier, right, which is provided, I'm thinking through the lenses of a health tech or a med tech company. And they've got their, you know, likely their team, whether it's an internal team or a consultancy that helps them, helps them put together this dossier. Most of the time, it seems like just a classic scenario where if I help you do your job better, right? So basically, the better this dossier, the more advantageous like it is going to be for me from a medical device company to get your buy-in. how often did that happen or most of the time where your dossiers were there a lot of like issues with the dossiers that you looked at where you just needed to do a mountain of work right just to

kind of fill in the gaps i got one dossier from a diagnostic company i won't tell you who and what they were looking at but scott the thing was this thick it was like 500 pages it was this monster document and and i'm like what makes them think i have any time to read this I mean, there were charts and graphs and figures and pictures and testimonials. And it was absolute garbage. I bet they paid some consultant 20 grand to put this thing together. I'm not joking you. I unzipped it out of the FedEx box that it came to me in.

I don't even remember how it arrived to us. Maybe they sent it right to the medical director and he handed it to me. And I opened it up. I scanned it for 30 seconds and I literally threw it in the garbage. I mean, now, if their market access team knew the Intermountain Healthcare took their $20,000 dossier and chucked it in the garbage with $20 million worth of research in it, they would have been heartbroken and furious. I said, look, I'll do a better job just doing my work and going to haze.com and typing in the name of this company and the name of the diagnostic test. Or if it's not the brand name,

trademark rights reserve type thing, it's the general, you know, single nucleotide polymorphic. detection for such and such cancer, you know, that type of. But let me go do my research, and in one week I'll have all the literature that was in the dossier. I'll spend more time going through this piece of junk than I would just cracking my knuckles and doing it myself. Good dossiers are maybe 100 pages long, four or five tabs in it. Tab one is analytical validity. Tap, even if you're a device, that's not typically a term we use in devices.

we usually use it in diagnostics, but analytical validity, clinical validity, clinical utility, and the last tab is health economics. And you should just have maybe a one-page sheet between each of those, every other bit inside that tab or just peer-reviewed studies that you've printed out and three whole punch. These don't have to be pretty. You don't have to have them bound. Like, you know, they just put a spiral binding in them and put it in the envelope and mail it off to the insurance company and be polite and beg them and say, we have a fantastic technology and we would greatly appreciate sickness consideration in this matter. We think we are going to improve the quality of life for your members. Sincerely, the market access team at XYZ Medical. Don't write me a letter

and yell at me. I got that a number of times. That was their introduction. Select Health is making a grave mistake and not covering this. We have petitioned you five times to no avail. And it's like, look, guys, I'm not going to deny you. I'm just going to review you in 2027. Right? Like, would you ever, as the CEO of Mattel, be like, stupid parents, why aren't you buying Barbie dolls for your little girls? Right.

You are so dumb. How dare you, you know. And it's like, look, guys, I don't have to cover you. I don't have to deny you. I'm just going to review you later. And maybe you'll learn some manners. And maybe you'll learn who. the actual customer is. I'm the one who people pay $2,000 a month to to manage their health care.

That's why it's called managed care. And if I don't like the evidence that I see, I don't have to reimburse for your technology. And if you're calling me every week and harassing me and saying, Nick, is your review done? Is your review done? As you review done? I mean, that's where the stuff gets very human. I don't want to pretend, Scott, like I did that every day. I mean, But that crosses your mind. I don't know that I ever did that, to be honest. But, yeah, no, no doubt. I think it's just, it's a really good point.

And I've, I've mentioned this on, you know, in some of the, some of these interviews. But I remember Stuart Butterfield, who's the founder of Slack, the messaging tool, a widely popular now. But he mentioned, like, one of the most, and I think he's, if I remember me, right, he's like, he's a product guy, right? He's an engineering kind of product guy by background. And he's like, one of the most important skill sets that. everyone needs to learn regardless of where they're at in a small company, large company,

regardless of the hierarchy is sales, right? Relationship building and sales. And that hearing you describe that, it's like that applies almost to anything, right? Like if they're trying to convince you or influence you to look at the data, to look at what their value proposition, it does like, when would a salesperson ever come in the door and yell at a prospective customer, right? I mean, the goal is to win someone over. so they'll, you know, they'll give your, they'll give your, your thing an honest, an honest, you know,

take, basically. You know what I mean? So it does remind me of that, you know, hearing Stuart Betterfield say that, you know. Scott, that's where there's two sales organizations within a well-designed medical company, whether it's diagnostic or devices or pharma or biotech or whatever. You have sales group A, which is called sales. They're the ones that talk to doctors and value analysis committee. sales group B is called market access or HEMA, HEMA, health economics and market access. These guys go talk to insurance companies and hopefully everybody comes together at the same time. Hopefully at the same time or maybe even after HEMA does its job, you have the, you know,

the physician says this is a really cool technology. Let's go back to EuroLeft. Is it reimbursed? And they go, I don't know. Let me call my HEMA team. Hey, guys, is this reimbursed by Aetna and SIGA? And they go, sure is. We just got coverage last month.

Hey, doctor, it sure is covered. And he goes, great, I'll buy 20 of them today. I have 20 patients right now that could use this. And Scott, that's, in my opinion, the role of the CEO in a biotech or device company is one of a maestro, that they are orchestrating when the data is released, you know, meaning when do the violins come in? And then when does the cello come in? And then when does the trumpet and the French horn come in? And you don't want this to come in too early.

It'll screw up the symphony. You guys need to wait a minute. You guys meaning nice or a big systematic literary view. We're not ready for that. We need to wait. That'll be next year. We'll do the systematic literature. But right now is the time for the Viand Lins,

which means a randomized prospective study that has been crafted by health economists, not by physicians. Again, because the people that care about that are the payers. And who speaks payer? Health economics and market access. They're fluent in that language. And so if the CEO is a good, I have a good friend here in Utah named Greg Critchfield,

Greg runs a company called Sarah Prognostics, that man is as good of a maestro as any CEO I have ever met in my life in the biotech world. And he's a fantastic maestro. of knowing when to bring in this piece, when to bring in this, hold on a minute, we're not ready for that. And he'll play the long game so that when he delivers a medical technology to the market, it has a perfect bow on it. The physicians are happy, the vac is happy, and the insurance company are all happy. And you go, how did he do it? How did, there's no infighting, no one's saying, guys, why are you sending me this? You have one retrospective study with six patients.

What made you think I would reimburse for that? There's none of the, that contention because Greg does a great job of being the maestro of that symphony and bringing in the right instrument at the right time so that at the end everyone is edified and there's no frustration. There's frustration as you're building this. But when you go commercial, you know, on that day that you're ready to finally go commercial, your dossier is polished. No one can say, oh, well, you don't work in pediatric patients. You go, yes, we do. We have the evidence. Nobody's, can say you haven't done health economic analyses to show cost effectiveness or cost minimization or cost utility or incremental cost effectiveness ratios or any of these things,

that he goes, yes, we have. PubMed ID, 1, 2, 3, 4, 5, go read it. That's just a beautiful orchestration. I love watching CEOs like that that know when to bring in what, at what time. Hey there, it's Scott. And thanks for listening in so far. The rest of this conversation is only available via our private podcast for MedSider Premium members.

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